J. Mayr

Analysis of dog bites in children who are younger than 17 years

OBJECTIVES. This study focuses on the pattern of incidence, mechanisms, and circumstances of accident and injury in a series of pediatric patients who sustained dog bites. METHODS. In our retrospective survey, the medical charts of all children who were younger than 17 years and sought medical attention after a dog bite between 1994 and 2003 were reviewed. To obtain the total number of each dog breed in the administrative district, we analyzed 5873 files from the community dog registers. For establishment of a risk index, the representation of a dog breed among the total canine population was divided by the frequency of dog bites from this breed. RESULTS. A total of 341 children (mean age: 5.9 years) were identified. The annual incidence of dog bites was 0.5 per 1000 children between 0 and 16 years of age. Incidence was highest in 1-year-old patients and decreased with increasing age. The relative risk for a dog attack by a German shepherd or a Doberman was ∼5 times higher than that of a Labrador/retriever or cross-breed. The vast majority (82%) of the dogs were familiar to the children. Most (322; 94%) of the children had injuries to 1 body region; in the remaining 19 (6%) children, up to 3 body regions were injured. Of 357 injuries, the face, head, and neck region was the leading site affected (50%). Inpatient treatment was required in 93 (27%) patients. CONCLUSIONS. Dog bites in children are frequent and influenced by the breed-related behavior of dogs, dog owners, children, and parents. Therefore, prevention strategies should focus on public education and training of dogs and their owners. Children who are younger than 10 years represent the high-risk group for dog attacks.

Ascent of the testis in children

Among 460 children who had an orchiopexy (ORP), we identified 72 children who had attended our institution 1–12 years earlier and in whom the testicular position had been specified. Of the 72 boys 19 were had ascended testes (26%). The age at ORP of the children with ascent of the testes was 7.0 years (1.8–14.0 years). Light and electron microscopy of 13 testicular biopsies taken at ORP, showed alterations of germ cells and sertoli cells, similar but less pronounced than alterations seen in congenital undescended testes.ConclusionA normally positioned testis may ascend into the inguinal region or upper scrotum and remain there fixed. This secondary cryptorchidism does not usually respond to human chorionic gonadotropin treatment and must be corrected by orchiopexy.

Baby walkers--an underestimated hazard for our children?

Baby walkers (BWs) continue to be a frequent cause of head injuries in young children. A random sample survey of 240 families with children aged 2–6 years revealed a use rate of bady walkers of 55%. Of the children using baby walkers 20% were found to have suffered a BW-related accident. In a retrospective study we reviewed 172 case reports of infants who suffered a BW-related injury between January 1990 and June 1993. We observed 19 skull fractures, 23 concussions of the brain and 125 contusions and lacerations of the head including 4 teeth luxations and 3 fractures or distorsions of the upper extremity. BW-related injuries represent the third most common mode of injury in children aged 7–14 months. We conclude that despite previous warnings BW still represent a frequent cause of severe head injuries in young children. We recommend a general ban on the sale and manufacture of BWs.

Undescended testicles: an epidemiological review.

In a retrospective study the records of 447 boys (median age 5 y, age range 2 wk to 12y) undergoing orchidopexy in a university hospital paediatric surgical department over a 2‐y period were analysed for epidemiological factors related to disturbed testicular descent by comparison with the notes of an equal number of otherwise healthy male trauma patients matched for age. There were higher rates of peripartal asphyxia and intrauterine growth retardation (reflected by lower birthweights in combination with equal gestational age distribution), more complicated deliveries, an increased incidence of congenital malformations and more frequent occurrence of a number of chronic diseases in the families of affected boys. First‐ and second‐born boys were over‐represented in the study group. A cyclical pattern for the month of birth is suggested by the data, but this did not reach statistical significance. Neither was any statistical difference found for premature delivery, the incidence of extra‐uterine fertilization, hormonal treatment of the mother while pregnant, twin pregnancies, threatened or imminent abortions or parental age. The literature dealing with this topic was reviewed. Discrepancies between different studies can be explained, at least in part, by considering different forms of undescended testicles as different nosological entities that should be assessed separately in forthcoming research.

Laparoscopy-assisted single-port appendectomy in children: is the postoperative infectious complication rate different?

AIM In childhood, laparoscopy-assisted single-port appendectomy (SPA), including the advantages of open and laparoscopic surgery, is not widely used. However, there is debate whether the retrieval of the infected appendix via the umbilicus results in a higher infection rate compared with other laparoscopic or open techniques. The aim of the study was to determine the postoperative infection rate and possible risk factors for infection after SPA in children. METHODS For this retrospective study, case notes of all children (n = 262) who underwent SPA between August 2005 and December 2008 were reviewed. Those children in whom the preoperative ultrasonography revealed suspected perforation were excluded from SPA and subsequently underwent open surgery. SPA was performed using a 12-mm trocar with one 5-mm working channel, introduced through a sub-umbilical incision. After grasping the appendix with atraumatic forceps, the appendix was exteriorized through the umbilicus and dissected outside the abdominal cavity as in open surgery. Preoperatively, each patient received one dose of Metronidazole and Cefuroxime, and the umbilicus was cleaned in particular. RESULTS Of the 262 children who underwent SPA, 146 were boys (55.7%) and 116 girls (44.3%). Median age at operation was 11.4 years (range, 1.1-15.9). Six obese (with a body mass index greater than the 95th percentile) children (2.3%) developed intra-abdominal abscess after perforated appendicitis that was treated with a course of antibiotics. One child required revisional surgery and drainage. The median length of antibiotic treatment was 3 days (range, 0-15). CONCLUSION In our institution, SPA is the method of choice for appendectomy in children with acute appendicitis, in whom preoperative ultrasound does not reveal signs of perforation. The infection rate (2.7%) after SPA is not increased compared with other laparoscopic or open techniques. Overweight (body mass index greater than the 95th percentile) and perforated appendicitis seem to increase the risk of postoperative infectious complications.

Spontaneous gastrointestinal perforation in very-low-birth-weight infants – a rare complication in a neonatal intensive care unit

Over a 6-year period (1989–1995), gastrointestinal (GI) perforation was diagnosed in nine preterm infants (mean gestional age 27 weeks, mean birth weight 872 g). Three presented with necrotizing enterocolitis (NEC), two with indwelling-tube-induced perforation of the stomach, one with small-left- colon syndrome, and another with meconium ileus. Spontaneous intestinal perforation occurred in two similar very-low-birth-weight (VLBW) infants, in the distal ileum, on days 8 and 9 of life, respectively. The only clinical sign was extensive abdominal distension, and abdominal X-ray studies revealed free peritoneal air. All findings were distinct from those associated with NEC. Their further clinical course was complicated by reperforation on day 32 and 39, respectively. They subsequently recovered and presented without GI problems at the corrected ages of 4 and 2 months, respectively. In contrast to high mortality of 57% in the group with non-spontaneous intestinal perforations, spontaneous perforation seems to have a good prognosis even in VLBW infants if diagnosed and treated promptly.

Late follow-up in patients with gastroschisis

During a 16-year period, 60 neonates with gastroschisis were treated at the Department of Pediatric Surgery in Graz; 6 died and 54 (90%) survived. A questionnaire was sent to 45 patients, who were called for a medical examination; 31 patients (69%) came to follow-up, 26 of whom reported minor abdominal problems that could be related to gastroesophageal reflux (GER). Fifteen agreed to 24-h esophageal pH monitoring and/or upper gastrointestinal series; in 7 pathological GER could be demonstrated. Manometric studies in 6 patients revealed a motility disorder of the esophagus. Only 4 children were concerned by a disfiguring scar or the absence of a navel. Heigtt and weight were within normal limits and the children had developed normally.

Treatment of medial epicondylar apophyseal avulsion injury in children

ZusammenfassungOperationszielOperative Reposition und Retention der Apophyse des Epicondylus ulnaris zur Vermeidung von Gelenkinstabilitäten, bleibenden Fehlstellungen und Pseudarthrosen.IndikationenAbsolut: Intraartikulär dislozierte Apophyse des Epicondylus ulnaris, komplette Läsion des Nervus ulnaris.Relativ: Dislokation der Apophyse (> 4 mm) bei Kindern > 5 Jahre, wobei die Indikation mit zunehmender Dislokation, steigendem Alter oder besonderer sportlicher Aktivität des Kindes großzügiger zu stellen ist.KontraindikationenDislokation der Apophyse (≤ 4 mm) bei Kindern < 5 Jahre, sofern das Fragment nicht intraartikulär liegt.OperationstechnikOffene Reposition der Apophyse über einen ulnaren Zugang. Identifikation des Nervus ulnaris. Bei jüngeren Kindern bzw. bei sehr kleinen Fragmenten Fixation mit Kirschner-Draht. Schraubenfixation bei größeren knöchernen Fragmenten und älteren Kindern.WeiterbehandlungOberarmgipslonguette bis zum Abschluss der Wundheilung. Anschließend Oberarmgipsverband für 3 Wochen. Entfernung der Kirschner-Drähte nach 4–6 Wochen.Schraubenentfernung nach 8–12 Wochen. Physiotherapie nur, wenn 6 Wochen nach Entfernung des Gipsverbands noch eine deutlich eingeschränkte Beweglichkeit des Ellenbogengelenks vorliegt.ErgebnisseIm Zeitraum vom 01.01.1994 bis 31.12.2003 wurden 25 Kinder mit einem Durchschnittsalter von 12 Jahren wegen eines Apophysenabrisses am Epicondylus ulnaris mit offener Reposition und Kirschner-Draht-Fixation operiert.Durchschnittlich 3 Jahre nach dem Unfall konnten 14 dieser Kinder entsprechend einem Schema, das subjektive, klinische und radiologische Parameter bewertet, nachuntersucht werden. Zwei Kinder zeigten eine geringe Minderung der groben Kraft des verletzten Arms im Seitenvergleich. Ein Kind wies ein Ellenbogenflexionsdefizit von 10° auf, bei den übrigen Kinder fanden sich Bewegungseinschränkungen von maximal 5° im Seitenvergleich. In allen nachuntersuchten Fällen zeigte sich eine minimale Zunahme der Valgisierung des Ellenbogengelenks der Frakturseite im Vergleich zur unverletzten Seite (durchschnittlich 3°). Alle Frakturen waren innerhalb von 6 Wochen knöchern konsolidiert.AbstractObjectiveSurgical reduction and retention of apophyseal avulsion injuries at the medial epicondyle to prevent joint instability, lasting malalignment, or pseudarthrosis.IndicationsAbsolute: intraarticular apophyseal dislocation of the medial epicondyle, complete lesion of the ulnar nerve.Relative: dislocation of the apophysis (> 4 mm) in children > 5 years of age; the need for intervention increases in children as the degree of dislocation, age, and athletic activity increase.ContraindicationsDislocation of the medial epicondyle (≤ 4 mm) in children < 5 years of age, provided the fragment location is not intraarticular.Surgical TechniqueOpen reduction of the apophysis through a medial approach. Identification of the ulnar nerve. In young children or with small fragments fixation with Kirschner wire. Screw fixation in older children or for larger fragments.Postoperative ManagementLong upper-arm plaster cast until wound healing is achieved. Subsequently, upper-arm plaster cast for 3 weeks. Removal of Kirschner wires after 4–6 weeks, screw removal after 8–12 weeks. Physiotherapy only if marked reduction of elbow mobility is found 6 weeks after cast removal.ResultsFrom January 1, 1994 to December 31, 2003, 25 children with an average age of 12 years suffering from medial epicondylar avulsion fractures were operated on using open reduction and Kirschner wire fixation. An average of 3 years after the injury 14 of these children underwent follow-up examination using a procedure that took subjective, clinical and radiologic parameters into account. Two children showed a slight reduction in overall strength of the injured extremity when compared with the contralateral extremity. One child had a flexion deficit of 10°, all other children showed movement limitations of ≤ 5° compared to the contralateral extremity. In all the cases available to follow-up, there was a slight increase in valgus alignment of the elbow joint compared with the uninjured side (3° on average). All fractures consolidated within 6 weeks.

Deszendierende intramedulläre Nagelung zur Behandlung dislozierter suprakondylärer Oberarmfrakturen im Kindesalter

AbstractBackground. Supracondylar humeral fractures are the most common lesions in childhood.Severely displaced fractures are commonly treated by crossed K-wire osteosynthesis.Such stabilized fractures require a cast and often involve postoperative complications such as iatrogenic lesions of the n. ulnaris and secondary displacements,sometimes leading to a consecutive cubitus varus.This study analyzed possible advantages of elastic stabile intramedullary nailing (ESIN) with postoperative release of motion. Patients and method. All children aged 1–14 years suffering from a supracondylar humeral fracture, with a displacement in at least two planes,were included in this study (period: 1 June 1999–30 April 2001).Movement was permitted for all patients postoperatively.A follow-up examination was scheduled at least 6 months after trauma. Results. This study included 20 female and 30 male patients.Neither iatrogenic lesions of the n. ulnaris nor secondary displacements occurred. Five slight technical pitfalls (perforating wire, gapping with consecutive axis deviation) occurred.Postoperative X-rays most often revealed a remaining axis deviation in the sagittal plane.Comminuted fractures with corresponding zones resulted in cubiti vari and valgi.Of the 50 patients, 47 appeared for follow-up (94%).The ROM coincided with the acquired radiological data. Only one patient (2%) showed a functional deficit greater than 10°. Conclusion. As soft tissue swelling does not hinder the surgeon, ESIN shows a high rate of closed stabilizations.No cast has to be applied and free ROM can be permitted for all patients.Avoidance of iatrogenic lesions of the n. ulnaris and secondary displacements are other advantages of this method.ZusammenfassungHintergrund. Die häufigste Läsion am kindlichen Ellenbogen ist die suprakondyläre Humerusfraktur.Bei stark dislozierten Frakturen ist die perkutane Osteosynthese mit Kirschner-Drähten eine Standardmethode. Diese erfordert eine Gipsbehandlung und geht mit bekannten postoperativen Komplikationen Schädigung des N. ulnaris, sekundäre Dislokationen, die einen Cubitus varus nach sich ziehen können, einher. In dieser Studie wurde untersucht,inwieweit die elastisch stabile intramedulläre Nagelung (ESIN) mit postoperativer Freigabe des Bewegungsumfanges bei der Versorgung suprakondylärer Oberarmfrakturen im Kindesalter Vorteile bietet. Patienten und Methode. In diese Studie wurden alle Kinder zwischen 1 und 14 Jahren, die vom 1.6.1999 bis 30.5.2001 wegen einer suprakondylären Oberarmfraktur mit einer Dislokation in mindestens 2 Ebenen behandelt wurden, aufgenommen.Bei allen Patienten wurde postoperativ die Bewegung freigegeben.Eine Nachuntersuchung zur Erfassung aller postoperativen Komplikationen wurde mindestens 6 Monate nach Trauma durchgeführt. Ergebnisse. In diese prospektive Studie wurden 20 Mädchen und 30 Jungen eingeschlossen. In keinem Fall trat postoperativ eine Schädigung des N. ulnaris oder eine sekundäre Dislokation mit daraus resultierendem Cubitus varus auf. In 5 (10%) Fällen traten geringfügige technische Komplikationen auf (Perforation des Drahtes, Klaffen des Frakturspaltes mit konsekutiver Achsenfehlstellung). Die Analyse der postoperativen Röntgenbilder ergab am häufigsten eine belassene Achsenfehlstellung in der Sagittalebene.Varisierungen bzw.Valgisierungen traten bei Frakturen mit entsprechender Trümmerzone auf. Es konnten 47 der 50 Patienten nachuntersucht werden (94%). Die Analyse des Bewegungsumfanges zeigte ein mit der radiologischen Diagnostik übereinstimmendes klinisches Bild. In nur 1 (2,1%) Fall betrug die Seitendifferenz des Funktionsdefizites mehr als 10°. Schlussfolgerung. Vorteile des Verfahrens sind die hohe Rate an gedeckten Stabilisationen, ohne auf ein offenes Manöver wegen stark geschwollener Weichteile umsteigen zu müssen, sowie die Vermeidung iatrogener N.-ulnaris-Schäden.Sekundäre Dislokationen mit daraus resultierendem Cubitus varus traten nicht auf.Die Übungsstabilität und gipsfreie Nachbehandlung sind möglich.

The effect of mode of delivery on outcome in fetuses with gastroschisis

The postoperative course in neonates with gastroschisis after successful surgical repair is complicated by prolonged ileus. Elective cesarean section (CS) has been advocated to limit damage to the bowel due to labor and compression in the narrow birth canal and to prevent retrograde infection. We reviewed the records of 58 infants with gastroschisis treated between 1977 and 1993; 12 were delivered by CS for obstetrical reasons and 46 were delivered vaginally (V). Mortality was higher in the CS group (V = 1/46, CS = 4/12). Both groups differed significantly with respect to birth weight and gestational age; gestational age, however, had no influence on morbidity and mortality. Primary contamination was significantly lower in the CS group (V = 29/42, CS = 3/12). However, no difference was found regarding infectious complications. No complications could be attributed directly to the mode of delivery. Since these data do not show any significant advantages of CS on morbidity and mortality, we do not recommend CS for fetuses with gastroschisis diagnosed prenatally.